Hacking the Hand

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Hacking the Hand

Robert Markison's passion for technology and the human body has made him one of the top surgeons working on repetitive strain injury.

We've enslaved the hand to data," says hand surgeon Robert Markison in a moment snatched from a day of patients suffering from repetitive strain injury. "This so-called epidemic has not yet crested."

Markison should know. Increasingly in his medical practice, he faces a torrent of patients afflicted with carpal tunnel syndrome and various other computer-induced ailments. "We're at an important point as hand-intensive primates," Markison adds. "We have to decide whether to reclaim the hand as precious. So far, we've failed."

Often compared to the asbestos crisis, repetitive strain injury, or RSI, was once called the occupational disease of the '80s. It never went away, so now it is called the occupational disease of the '90s. Not only are RSI complaints the fastest growing category of occupational illness, but the surgery to treat carpal tunnel syndrome is one of the most common in the US - amounting to an estimated 230,000 operations a year. In some large workplaces, so many of the people on staff are wearing splints that the office seems a victim of some oddly selective carnage.

The huge rise in RSI, Markison says, can be nailed to the door of inventions that were meant to make work easier - computerized word and number processors. "Computer keyboards are a dreadful device. They're one of the worst mass-produced items of the 20th century," says Markison. The single-mindedness of the design offends him. "They decided not to integrate feet. They decided to make you sit. They decided to make you devolve into a lizardlike creature splayed out flat on a keyboard."

The mouse fares no better under his scrutiny: "They're ridiculous. The hand is not a sustained pointing device; it's a gesturing device. The mouse is a sign of terrific disrespect to the hand."

Though Markison has become internationally known for his innovative approach to treating musicians with RSI, their cases form a minority of his workload. Computer jockeys are the most common RSI sufferers, but they are joined by carpenters as well as assembly-line workers.

But Markison's critique doesn't stop with the "dreadful" machines: he also condemns "bad design and homogenized work lives" and - while convincingly denying that he is a Luddite - the way the good life has been diminished by consumerism.

The waiting room of Markison's office, high in an old San Francisco medical building, hints at his determination not to lead a "homogenized work life." The office is stocked with magazines - Lapidary Journal, Sew News, MacUser - that reflect his eclectic ways: he illustrates his own articles; studies smithing, gem carving, and glass blowing; produces animated videos; sews clothing; plays jazz; performs magic tricks; cobbles his own shoes; paints his own clarinet and saxophone (then hangs the artwork in the office). His nonmedical pursuits might seem merely a grab bag of high- and low-tech hobbies if they weren't part of a concerted effort to be freed from poor design. He collects skills the way some people collect information: so he will have the power to fix bad tools or artifacts.

Called by colleagues innovative, imaginative, and eccentric, Markison has taken his lifelong preoccupation with the precise workings of beautiful instruments and used it to turn himself into one of the top hand surgeons in the country. "A lot of surgeons don't ever want to see another RSI patient because they need unlimited care," Markison says. "But I'm fascinated by it. You cannot detach the psyche from the life of the hands."

And there's something else that seems to motivate this unusual physician: one patient calls it his "hacker's mentality." With musicians, Markison's impulse is to adjust the instrument; with office workers, his impulse is to reprogram the workplace.

The clinician

Markison proudly declares that he helps up to 90 percent of his patients avoid surgery. Office visits are the most important part of his work, and he launches into them with an unbending intensity, through many long hours.

His first RSI patient of the day walks in smiling. Though her hands hurt so much she can work only four hours a day, her employer is cooperative, her therapy is producing results, and she hopes to work three quarters or full time soon.

"I've really made lots of changes at work," she declares. She now has a speaker phone and has stopped using the computer and 10-key calculator. "There will not be another overtime hour in my life!" Her physical therapy includes training at a gym to increase strength, and she boasts that the grip in her right hand is almost back to normal.

When he examines patients, Markison strokes their hands and fingers. He taps their wrists and the backs of their hands, looking into their faces. He turns their hands over. He takes a length of wire - a paper clip, uncurled into a U - and, shielding it from view, touches their fingertips. "One point or two?" he asks. "One or two? One? Or two?" Often they feel only one point when two are denting the skin.

To explain surgical procedures to patients, he'll sometimes take a marker and draw on his hand, mapping bones and tendons, sketching incisions. When he doesn't draw on his hand, patients are apt to leave the office with a sketch. Markison likes to record his diagnoses as drawings on letterhead. "Rather than put down Greek and Latin terms, I put down exactly what I'm thinking. I'm trying to get to spareness," he says.

His favorite image for spareness comes from Japanese poetry. "If it's information it should aim toward haiku. Not flowery, not fluffy, not billowy. It should be crisp.

If you can't say it in a few words, then you don't know it."

Markison himself speaks epigrammatically. Indeed, he is often so eager to get his insights across that he becomes a torrent of haiku.

"We're becoming a blue-collar species."

"We'll enter data into the grave."

"We're biting off chunks of bad design all day."

"We've got cockroaches laughing at us."

"I want every patient to do what Gretel did in "Hansel and Gretel." I want them to do a self-rescue."

"The upper limb is the lightning rod to the soul."

His next patient, a reserved, well-dressed woman in her 50s, has had carpal tunnel surgery in both wrists but has been unable to work for over a year. The scars from the surgery Markison performed are small and tucked into natural creases, so they are virtually undetectable. Listlessly, she says she's fine, but Markison's probing reveals that she is at a loss to know what work she can do with RSI, and that she has little emotional support at home.

As he palpates her thumb, Markison suggests psychotherapy with someone sensitive to psychological stress from hand injuries. She assents and he writes out a prescription.

"The good news is that the thumbs are more capable than they were," he tells her. "You'll be successful."

The next visitor, a young man, also seems despondent. He has had RSI for two years, and his symptoms are getting worse. He has a part-time job running a computerized cash register. "Is that why your arm is worse? Do you have to do this?" Markison asks.

"Well, I need the money."

What distresses the patient the most is that he can no longer work out because of his injuries. "I used to work out a lot.

I was in really good shape."

"'Don't aspire' is my advice. Don't aspire to some incredible mantle of muscle."

"I wasn't aiming to be Schwarzenegger. But I was athletic. I played basketball...."

Preceded by hundreds of pages of files, a patient comes in for a one-time assessment. She cannot use a keyboard, write, or drive for long periods. She ascribes her condition to working as a customer service representative for a large insurance company. Markison inquires into the dates of her jobs and her duties, all involving constant keyboarding.

"Do you think you'll ever use a computer again?"

She grimaces. "If I work up to it and grin and bear it."

"Did you like computers before?"

"Yes."

"Now?"

"No. I'm scared of them."

She is retraining to be a nurse. Markison asks whether this is better for her than working for the insurance company, and she nods. "It's something I should have done a long time ago."

Not all of the RSI cases Markison sees are job-related. "Now it's Net-related injuries - people who are unable to break away from the keyboard. The question now is, 'Are you online?' Employers may soon resist compensating employees for RSI as a work-related injury because of the growth of the Internet."

Most of Markison's patients are women. "The demographics of data entry are not democratic," he says, adding that because women have, on average, a slightly lower body temperature, they are more inclined to be "cool-handed." Cool hands, he says, are more apt to injury and slower to heal.

Patients come to the office with injuries from accidents, congenital defects, and arthritis, but the majority suffer from RSI. Markison says he sees an average of 20 patients a day with overuse problems. Most are computer operators, but some are candy packers, guitarists, sculptors, antique rug restorers. "I do my best to extend their warranties," he says, adding that he treats two vastly different populations: "the creative group that wants to work smarter and will do anything, and the people involved in some kind of dreadful work that's repetitive. They're asking my permission to change what they do - but only they can decide to do that."

The hacker

Markison is a slender man of average height with a small moustache and goatee and observant dark eyes. His hands are muscular, with more space than usual between the first and second fingers of his right hand. His quiet demeanor doesn't disguise a tremendous intensity. He seems to restrain himself from saying many of the things he'd like to say - and to be delighted when people ask the questions that let him utter these thoughts.

Markison grew up in a family of resourceful people. Relatives routinely made clothing of couture quality, upholstered their furniture, repaired Swiss watches, and hooked rugs. His suburban Maryland neighborhood contained hot-rod buffs; Markison admired their ability to machine parts. ("On computers, you void the warranty if you go inside," he complains.)

Soon he was applying these lessons. At 10, he played in the school orchestra, where he was bullied by "a corpulent guy of no talent - but sitting ahead of me in the clarinet section." As with many people, the flexor tendons of Markison's ring and little fingers are linked, making it hard to key certain notes. This seemed to stand in the way of becoming a professional clarinetist, "which I wanted as part of my life." His response: to take apart his clarinet and have several keys recast by a silversmith and put closer together. He was moved to first chair.

Today he uses similarly ingenious approaches with those of his patients who are professional musicians. A favorite technique is to videotape the musician playing, scan frames into the computer, and use the image to pinpoint troublesome motions and map ways to redesign the instrument. He has also been known to prescribe changes in musical genre or to suggest rehearsing on an instrument less problematic than the one used in performance - a notion some musicians find heretical.

"Bob's one of a rare breed of surgeon who is looking for nonsurgical solutions, trying to fix other things first before rearranging the anatomy," says Dr. Frank Wilson, a neurologist who specializes in musicians' hands.

Thus, Markison's characteristic response to many of the problems he sees in nonmusicians is "to invent my way out of trouble." He steers patients toward ergonomically designed keyboards and voice-activated computers, and he suggests ways they might change their work habits (and sometimes their jobs).

In coaching his patients about lifestyle changes, Markison is deliberately self-revealing. He tells his patients about his sewing and cobbling, his philosophical views, his vegetarian diet. "I have to exist as an emblem of a person who's independent," he explains.

He notes that in medieval times, the word doctor meant teacher. Seeing himself above all as an educator, what he imparts is more than just medical data. "Most people sleepwalk into illness because of a failure to be vigilantly self-tending and awake."

But doesn't he see people who don't want to be students? "All the time. They say, 'Let's get on with it!'" says Markison, snapping his fingers. "'What is the treatment? Let's do it.'"

Perhaps aware that seeing himself as an emblem, as a model, might ring of hubris, Markison studiously runs through some of his own weaknesses.

"I've learned tremendously from being bald. I've learned a lot from having feet that didn't feel good in off-the-shelf shoes. So, I celebrate every foible I have. I'm not part of the under-30 youth and fitness culture. I'm self-accepting - as much as I can be - and it really helps me every day."

Among the shortcomings he acknowledges is his own mild case of carpal tunnel syndrome, which he's had in his left hand for 10 years. "I tingle every day," he says gravely. To protect his wrist, he uses voice-activated software for correspondence. He cultivates ambidexterity, painting with a brush in each hand. He has mild arthritis in his left thumb, acquired as a high school gymnast, but is tolerant of the thumb's weakness. ("This joint is only 40,000 years old in evolution, in the context of 1.2 million years to 1.8 million years for the hand.") To protect it, he has given up gymnastics and forswears anything that requires flat-handedness. He wouldn't dream of doing a push-up.

He shows off his voice-activated Kurzweil software by dictating a report to an insurer. Markison's well-modulated voice becomes robotic as he intones commands that conjure up paragraphs of frequently needed boilerplate. Or he dictates new text, word by word. "I. Do. Not. Think. She. Needs. Any. Additional. Surgery. She. Needs. To. Change. Jobs."

Clearly, this is a man who adores a good machine, one that extends, rather than tethers, the human body. He cannot resist describing the charms of an improved pressure cooker, an electric speed needle that allows one to do needlepoint without strain to the hand, or his state-of-the-art X-ray machine, which nestles in a corner of his office ready to take and display radiographs at a moment's notice.

Markison has produced animated, interactive videos to teach medical techniques, including A New Rapid Repair Technique for Stab Wounds to the Heart and Sleight of Hand Coin Magic for the Training of Surgeons' Hands. After developing tennis elbow while windsurfing, he patented a reengineered handgrip for the sport.

In his surgical kit are several instruments he's made, including a prototype of the Markison Retractor. Invented to keep the edges of a surgical incision open, "it basically acts as an assistant to help me expose little surgical areas." He sand-cast it out of aluminum in his back yard, and then used lathe and milling techniques to make stainless steel attachments. He's also used steel and silicon to make a microforcep with a more comfortable handle and cast glass for a tendon-rolling jig.

Not content to merely invent tools, Markison would like to reinvent the role of the hand surgeon. He left a robust practice with other specialists, ditching a huge office in a San Francisco art deco high-rise for his one-man show far from downtown. What he lost in camaraderie he gained in creativity; what he lost in support personnel he gained in computers.

The surgeon

Early in the morning, I wander around a lounge in the teaching hospital at the University of California in San Francisco as it fills with nurses and doctors waiting for operating rooms to be prepared.

One nurse jokes about doing lengthy vascular operations with Markison when he was a resident. "About three hours in, he'd pull a silver dollar out of the patient's aorta and say, 'Well, no wonder this man's having circulation problems.'"

A minute later, Markison speeds by, wearing a three-piece suit. Almost at once, he reappears in scrubs. The operation I have come to witness seems a perfect match of surgeon and patient. The patient is a scientist, undismayed by the sight of her own internal anatomy, and eager to be rid of the cyst on her finger. It is a delicate job, since the cyst - actually a benign tumor - lies on top of a valuable tendon.

When all is ready, Markison stands looking at the finger for a long time.

Slowly, moving with utter concentration, he marks where he will cut. The patient, under local anesthetic, asks what's happening, and Markison takes down the drape to explain, first drawing a chevron across the knuckle of his finger, then showing her how he will make a cut of the same shape on her own. He will excise the chevron so that after the tumor is removed, the edges will fit neatly together.

"Fantastic!" cries the scientist.

Markison holds the scalpel in his right hand with the little finger extended for tension and balance, like the outrigger of a canoe. On the left hand, which holds a retractor, the little finger is curled under, out of the way.

He cuts neatly around the encapsulated tumor, looking for the point of attachment. He describes it to the patient, using medical terminology first and then plain English to say that it arises just below the nail bed.

As he closes the incision, Markison mentions the house dress and slippers he sewed over the weekend for his daughter's Tweety-Pie doll. Learning that both the surgical nurse and the patient sew, he describes his surgical technique: "This is like a milliner's blind stitch, where the crown of the hat joins the brim of the hat."

The patient notes, "I did that to a turkey once."

The meta physician

"I probably would be bored with a 40-hour week because there isn't enough substance in it," says Markison of his 12-hour days. "It doesn't mean that I'm a workaholic. It really means that I love continuity." It also means that he works through lunch.

When he's not working, Markison directs his intensity to nonmedical pursuits and to his family - his wife, Jean, to whom he has been married for 22 years of "relentless bliss" (through his medical education and her passage through law school and graduate work in English), and their three daughters.

Markison's extracurricular life leaves some of his colleagues frankly astounded. Emil Pascarelli, an occupational physician and the author of Repetitive Strain Injury: A Computer User's Guide, praises Markison for his sophisticated understanding of the hand, his eagerness to try nonsurgical treatments, his versatility, and his kindness. "He makes his own operating tools, he plays several musical instruments, and - maybe he doesn't want people to know this - he makes his own clothes."

But it's no secret. In his office, Markison pulls out a box of ties. "Neckwear's a very personal matter, and I'm not about to get generic about it." There are bolo ties he's made of pewter, pressed leather, SuperSculpy on rosewood, Limoges-process enamel. He displays silk ties, midnight blue, painted with an emergent butterfly, goldfish blowing bubbles, and something that may be a horseshoe crab or a UFO.

After learning to make ties, Markison moved on to the far trickier skill of shirt making. He sews his own shirts, pants, and suits, in stunning fabrics - fine wool crepes, subtle tweeds.

Markison's fervent eclecticism is on exhibit in his personal office: amid the medical texts and drafting table is a tailor's dummy, and on a tilting stand, a large embroidery hoop displays a half-completed wall hanging that echoes an image also on his letterhead: superimposed on a heart are two hands crossed to form an inverted heart. They are the hands of his daughter Louise.

Pulling the hoop toward him, Markison points out that the backing is Scottish linen, the blue yarn a natural fiber. He might be some fugitive from modernity, working in a log cabin lighted by kerosene, until he begins to embroider with a gun-shaped device - the electric speed needle. "I'd be a fool to thrash my hands and thumbs on some kind of busywork in the name of honoring the ancients," he says, outlining the heart.

"Women I operate on are happy when they see my top stitch," Markison says. "They look at my shirt. 'Did you make that shirt?' 'Did you do the top stitching?' 'Yes.' 'Well, you can operate on me.'"